The American Gastroenterological Association (AGA) has released updated clinical practice guidance on the surveillance of metaplastic and premalignant conditions of the esophagus and colorectum in older adults.

Published in Clinical Gastroenterology and Hepatology, the expert review and practice update provides a brief synthesis of existing literature and frames studies to foster nuanced decision making on surveillance cessation in older adults.

Among the AGA’s main takeaways:

• Comorbidities and life-expectancy tools may help differentiate which older adults are most likely to benefit vs those most likely to be harmed by surveillance.
• Continuing endoscopic surveillance of Barrett’s esophagus should be based on shared decision-making that examines factors such as comorbidities, life expectancy, risks, and benefits, as well as patient preferences.
• Tools for predicting dysplasia progression in Barrett’s may help contextualize the time frame for developing adenocarcinoma within an individual’s life expectancy.
• Inability to tolerate endoscopic therapy, surgery, or oncologic interventions for esophageal adenocarcinoma should lead to cessation of Barrett’s surveillance regardless of age.
• Continuing colorectal cancer screening in individuals older than 75 years should be based on individualized assessment of benefits, screening history, comorbidities, and risks. The clinical decision-making process for colonoscopy should be clearly documented in the electronic health records of individuals in this age group.
• Published studies of the use, effectiveness, de-implementation, and costs of colonoscopy in older adults should inform practice decisions for patients and clinicians.

“The US population is aging, and with the numerous GI [gastrointestinal] conditions for which people are under endoscopic surveillance, the timing was right to evaluate our current state of practice and think about if, when, and how to stop surveillance based on balance of benefits and harms,” lead author Audrey H. Calderwood, MD, MS, a gastroenterologist with the Center for Digestive Health at Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, told Medscape Medical News.

Calderwood added, however, that the update features no major departures from previous guidance. “Existing guidance was mostly around definitions of high-risk populations in whom surveillance should be performed, along with details around age of initiation and intervals of surveillance, with little guidance around when to stop,” she said. Previous guidance on stopping, at least for colorectal cancer polyp surveillance, offered some general principles around weighing risks, benefits, and comorbidities.

“In this update, we’ve aimed to provide more detailed practice guidance regarding stopping surveillance that hopefully that can be implemented in daily clinical practice,” she noted.

Calderwood and colleagues considered potential constraints in practice settings and patient preferences that might influence stopping surveillance but do not expect any of the recommendations to be controversial. “It’s possible that if an endoscopist’s perception of the 5- or 10-year risk of colorectal cancer among older patients who have had an advanced polyp is heightened above what the literature shows, or if an endoscopist remains worried, then he or she may not agree with stopping surveillance in patients with a life expectancy of less than 10 years if they have had an advanced adenoma in the past,” she said.

The guidance also presents sensitive ways to broach surveillance cessation with patients. “I hope they’ll appreciate the considerations we’ve outlined in thinking about when and in what situations surveillance can be reasonably stopped,” Calderwood said. “They might actually feel relieved to know long-term cancer risk is lower than they may have otherwise perceived and also feel free in not needing additional testing in their eighties and nineties so they can focus on other things that matter to them.”

Commenting on the update but not involved in it, Samir Gupta, MD, MSCS, a professor in the Division of Gastroenterology at University of California, San Diego, and a staff physician in the San Diego Veterans Affairs Healthcare System, said the recommendations provide much-needed guidance on continuing or deprioritizing screening and surveillance.

“The issue is challenging because the most common strategies used for screening and surveillance for these conditions — upper endoscopy and colonoscopy — are invasive, with complications that go up with age, and because the incremental benefit of additional procedures in people who have already had regular screening or surveillance is uncertain,” he told Medscape Medical News. Further, preventive benefits often take many years to be realized, while older adults may have comorbid conditions that lower the chances they will survive to realize those benefits. “Most gastroenterologists, however, have an intuitive sense that it takes a long time to benefit from screening and surveillance, and that older adults — particularly those with significant health concerns or frailty — are unlikely to realize a benefit.”

While the update’s guiding principles should be easy to implement, Gupta added, many clinicians do not routinely have these discussions, and there are few tools to facilitate them tactfully. “Some older patients may object, feeling that the system is somehow giving up on them or that projections for life expectancy don’t apply to them. That’s why it’s key for these discussions to happen between a patient and their trusted clinician, and for clinicians to consider the different framing approaches to these discussions presented in the documents.”

Looking ahead, Calderwood cited the need for more data on esophageal and colorectal cancer risks in older adults after serial surveillance examinations over their lifetimes. “We also need more information around how best to de-implement surveillance, especially in practice settings where surveillance recall is automated,” she said. “Future work should also focus on how best to frame conversations about mortality and morbidity related to surveillance while considering life expectancy.”

Added Gupta, “We also need more evidence on whether screening or surveillance in older adults does confer benefits with respect to reducing cancer incidence or mortality. We also need more studies that evaluate interventions for helping patients and clinicians make decisions on whether and when to deprioritize surveillance and screening.”

This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board. Calderwood disclosed having no relevant conflicts of interest. Gupta reported consulting for Guardant Health, Inc, Freenome, Geneoscopy, CellMax, and Universal Diagnostics.